UC Irvine Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health
Title Rhabdomyolysis-Induced Severe Hyperkalemia
Permalink https://escholarship.org/uc/item/5zw91341
Journal Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 10(4)
ISSN 1936-900X
Authors Rosenberry, Clark Stone, Franco Kalbfleisch, Kristine
Publication Date 2009
Peer reviewed
eScholarship.org Powered by the California Digital Library University of California Im a g e s In Em e r g e n c y Me d i c i n e
Rhabdomyolysis-Induced Severe Hyperkalemia
Clark Rosenberry, MD Madigan Army Medical Center, Department of Emergency Medicine, Fort Lewis, WA Franco Stone, NREMT-P Kristine Kalbfleisch, MD
Supervising Section Editor: Sean Henderson, MD Submission history: Submitted May 24, 2009; Accepted June 1, 2009 Reprints available through open access at http://escholarship.org/uc/uciem_westjem [West J Emerg Med. 2009;10(4):302.]
A 22-year-old male was brought in by paramedics who found him unresponsive at home surrounded by drug paraphernalia. He had a blood pressure of 84/50 mm Hg; oxygen saturation of 88%; irregular pulse; and Glasgow Coma Scale of 3. His skin was cool, diaphoretic and ashen in color, except for a grossly erythematous right arm. Lab work demonstrated an initial creatine kinase of 5,414 U/L that increased to 165,300 U/L by the next day. His potassium was 8.6 mmol/L. Hyperkalemia, defined as a potassium level greater than 5.5 mmol/L, is a potentially fatal disorder that occurs in as many as 10% of hospitalized patients.1,2 Causes include rhabdomyolysis, hemolysis, renal failure, acidosis, and medications.2 Cardiac conduction can be impaired, resulting in dysrhythmias. Electrocardiography (ECG) is important because it may be diagnostic and dictate emergent treatment. The first ECG changes seen are shortening of the QT interval, peaked T waves, and ST segment depression, followed by widening of the QRS complex, increased PR interval, and decreased P wave amplitude. Lastly, the P wave disappears and the QRS widens until it resembles a sine wave. Ventricular fibrillation or asystole may follow. Emergent treatment with calcium gluconate or calcium chloride is indicated to stabilize the myocardium if ECG changes are present.2,3 2 Serial doses of calcium are given until the ECG normalizes. Figure 1. Rhythm strip of lead II demonstrating severe Inhaled albuterol, intravenous sodium bicarbonate, and hyperkalemia. intravenous insulin with glucose should be used to temporarily shift potassium back into cells.3 Furosemide and sodium polystyrene should also be administered to increase the REFERENCES excretion of potassium. Hemodialysis may be required in the 1. Montague BT, Ouellette JR, Buller GK. Retrospective review of the setting of renal failure or severe cases. The ultimate treatment frequency of ECG changes in hyperkalemia. Clin J Am Soc Nephrol. goal of hyperkalemia is to identify and correct the underlying 2008; 3:324-30. etiology. 2. Garth D. Hyperkalemia. eMedicine Web site. Available at: http:// emedicine.medscape.com/article/766479-overview. Accessed May Address for Correspondence: Clark Rosenberry, MD, Department 3, 2009. of Emergency Medicine, Madigan Army Medical Center, Fort 3. Weisberg LS, Dellinger RP. Management of severe hyperkalemia. Lewis, WA. Email: [email protected]. Crit Care Med. 2008; 36:3246-51.
Volume X, n o . 4 : November 2009 302 Western Journal of Emergency Medicine